Diabetic Testing Supplies Prior Authorization Criteria Medicare Part B
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Defines Capital Blue Cross Medicare Part B prior authorization requirements for diabetic testing supplies (test strips, lancets, meters) and identifies preferred vs nonpreferred products; applies to providers and Medicare Part B members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Prior Authorization Approval Criteria
Evaluation: Diabetic testing supply target(s) will be approved when BOTH of the following are met:
Client-determined preferred products list applies
Continuous glucose monitoring devices are explicitly excluded from this prior authorization program. The program applies to diabetic testing supplies such as test strips, lancets, and meters, but continuous blood glucose monitors (CGMs) are not included in the program.
Coding — Preferred and Nonpreferred Products
| GPI=94100030006100 | Contour/Contour Next Test Strips |
| GPI=97202010006200 | Contour Blood Glucose Monitoring System |
| GPI=97202010006400 | Contour Next One Blood Glucose Monitoring System |
| GPI=97202010006410 | Contour/Contour Next Blood Glucose Monitoring Systems |
| GPI=94100030006100 | Blood Glucose Test Strips |
| GPI=94100030006020 | Test cartridges |
| GPI=97202010006200 | Blood Glucose Monitoring Device |
| GPI=97202010006400 | Blood Glucose Monitoring Kit |
| GPI=97202010006410 | Blood Glucose Monitoring Kit |
Provider Actions and Prior Authorization Workflow
Prior Authorization Required for Nonpreferred Products
Prior authorization is required for nonpreferred diabetic testing supplies. One preferred Ascensia product (e.g., Contour/Contour Next test strips or system) must be tried and documented by the prescriber before a nonpreferred product will be authorized.
- Preferred products: Ascensia/Contour/Contour Next (GPI examples: 94100030006100; system GPIs: 97202010006200, 97202010006400, 97202010006410).
- Nonpreferred products: non-Ascensia blood glucose test strips, cartridges, devices, and kits (see GPI ranges in source).
- OneTouch products: covered at 20% coinsurance and do not require PA.
Preferred-product Trial Required
Step requirement: the prescriber must document a trial of ONE preferred Ascensia product prior to requesting authorization for a nonpreferred diabetic testing supply. Documentation should specify which Ascensia product was used and the clinical rationale for switching to a nonpreferred product.
- Prescriber must provide evidence of trial of ONE preferred Ascensia product (e.g., Contour/Contour Next strips or system).
- If the patient could not use the preferred product, the prescriber must describe the limitation or failure that precludes its use.
Documentation Required from Prescriber
Provider must supply evidence that the patient meets the authorization clinical trigger and that the preferred-product trial requirement is met. Acceptable documentation includes medication history showing treatment with a diabetes medication or a concomitant drug affecting blood sugar within the past 90 days, or documentation of gestational diabetes, prediabetes, or diabetes.
- Clinical trigger: treatment with a diabetes medication within the past 90 days, OR treatment with a concomitant drug that may affect blood sugar within the past 90 days, OR diagnosis of gestational diabetes, prediabetes, or diabetes.
- Documentation of the preferred Ascensia product trial and clinical reason for failure/limitation of the preferred product.
Denial Triggers for Prior Authorization
Requests for nonpreferred diabetic testing supplies may be denied if BOTH the clinical trigger (see documentation requirements) and the preferred-product trial (ONE preferred Ascensia product) are not met or not adequately documented.
- Denial may occur when clinical evidence of diabetes treatment or qualifying diagnosis within the past 90 days is absent.
- Denial may occur when prescriber fails to document trial of ONE preferred Ascensia product or adequate rationale why preferred product cannot be used.
Definitions
Background
Blood glucose test strips, lancets, and meters are used for quantitative self‑monitoring of blood glucose by people with diabetes and in clinical settings. This program covers those diabetic testing supplies for Medicare Part B members and defines prior authorization requirements for nonpreferred products; it does not apply to continuous glucose monitoring systems.
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